Health Transition Fund Mid-Term Report (May 2000)
About This Mid-Term Report
The purpose of this report is to provide a mid-term overview of the Health Transition Fund (HTF) and its activities to date. It discusses, in general terms, the projects that have received funding, the four priority areas that they focus on and the rationale for the HTF. It also begins to lay out how we plan to ensure that the valuable information flowing from HTF projects becomes widely and appropriately disseminated so that it can be of practical use. While these efforts have begun, much of the future work will relate to the analysis, dissemination and use of results.
We also felt it was timely to share some of the things we have learned so far - from a program and a
project point of view. These observations are based on experiences so far with both developing and
implementing the program, and the planning and carrying out of individual projects. We hope that
funding programs developed in the future can benefit from our experiences. We also hope to show
project proponents that the challenges they are facing in planning and carrying out their own project are
often shared by others.
Accordingly, this Mid-Term Report should be of interest primarily to project investigators, and to people
working with the federal, provincial and territorial governments. We hope that it will provide a basic
understanding of the HTF - who we are, what we are doing and where we are going.
Page 17 explains how to contact us for more information on the HTF.
Why Was The Health Transition Fund Created?
The Government of Canada created the Health Transition Fund to support a number of health-related
pilot and evaluation projects. The purpose of the projects was to generate evidence and information that a
range of decision makers - such as governments and regional authorities - could use to make better, more-informed decisions about how health services should be organized and delivered to best meet the needs
of Canadians. The three-year, $150 million Fund was announced in the Government of Canada's
February 1997 budget in response to a recommendation by the National Forum on Health. The Forum
recommended establishing a multi-year fund to support pilot projects to test new approaches related to
Home Care, Pharmacare and Primary Care, which would help to create or move toward a more integrated
health system.
The 1998 HTF Conferences... Ideas and Dialogue
In addition to establishing and implementing the funding program, the HTF supported three
national conferences in early 1998.
- The Conference on National Approaches to Pharmacare, held January 18-20, 1998 in
Saskatoon and co-hosted by Saskatchewan Health and the Health Transition Fund;
- The National Conference on Health Info-Structure, held in Edmonton from February 8-10,
1998 and co-hosted by Alberta Health and Health Canada's Office of Health and the
Information Highway; and
- The National Conference on Home Care, held March 8-10, 1998 in Halifax, and co-hosted
by the Nova Scotia Department of Health and the Health Transition Fund.
These events were intended to stimulate discussion among a wide range of stakeholders from all
parts of Canada on important health-system issues. While the intent of the conferences was not
to identify HTF project topics, some ideas from the conferences have been addressed in
projects. Proceedings from these conferences are available from the Secretariat, and summaries
are available on the HTF web-site.
The HTF has given service providers, researchers and governments a vehicle for testing practical
approaches to delivering health care to see if they work, and under what conditions. Central to the HTF is
ensuring that the lessons learned and information generated by the projects are shared with the right
people.
Collaboration: A Basic Element of the HTF
The $150 million is being provided by the Government of Canada. However, the HTF is a collaborative
effort involving the federal, provincial and territorial governments. Accordingly, the structure and
operations of the Fund reflect the input of all governments (13 initially, and 14 as of April 1999, when
Nunavut was created). For example, from the outset of the HTF, federal, provincial and territorial
Ministers agreed to fund projects relating to four priority areas - Home Care, Pharmacare, Primary
Care/Primary Health Care, and Integrated Service Delivery. (We will provide more information on these
areas later.) Mechanisms - such as an ongoing group called the Federal/Provincial/Territorial Working
Group on the Health Transition Fund - are also in place. They enable the various levels of government to
collaborate on the Fund's design and key program elements. The program is managed by Health
Canada's Health Transition Fund Secretariat.
What Projects Are Being Funded?
The Health Transition Fund is supporting 141 projects. These are projects that either evaluate existing
models of health services or approaches to delivering them, or which pilot and evaluate new models of
service delivery or variations of existing models. Essentially, the HTF supports projects designed to
generate new knowledge rather than confirm existing knowledge. The projects chosen for funding also
have to relate to the four priority areas (described in more detail on pages 5 to 6).
The HTF has received many calls and proposals about funding for other types of projects. However, it is important to note that the Fund was not created to either support academic research projects or implement proven service models. Nor does it provide developmental funding.
Evaluation: A Critical Component Of All Projects
Early on, the HTF developed an evaluation framework consisting of four broad questions:
- How did the project affect the quality of services and care provided, access to services and the
integration of services?
- Did the project lead to changes in the health of the population being served?
- Was the model, program or service evaluated as being cost-effective? What were the cost
implications?
- What lessons were learned about the implementation and testing of this model or program that might
be useful to others?
As part of the evaluation process, and where appropriate and feasible, every project must answer these
questions in its final report.
Our Four Priority Areas
As noted earlier, federal, provincial and territorial governments have agreed upon the following four
priority areas on which the Health Transition Fund will focus:
- Home Care
- Pharmacare/Pharmaceutical Issues
- Primary Care/Primary Health Care
- Integrated Service Delivery
We chose these priority areas for three reasons. First, they reflect the broad priorities of a range of parties
involved in health care at the federal, provincial and territorial levels. Second, changes in these areas are
clearly occurring across Canada. Third, policy and program work was already underway in them, and this
work needed better evidence to support it. In essence, the four areas were already relevant to
governments, administrators and those who develop health policy.
The wording of the following definitions has been agreed-upon by a wide range of participants for the purposes of the HTF.
Home Care
Home Care describes a range of services which enable people, incapacitated in whole
or in part on either a temporary or ongoing basis, to live at home. Home care services
are part of the broader effort to improve the health and well-being of Canadians. These
services often prevent, delay or provide a substitute for long-term care or acute-care
alternatives. Home care may be delivered under many organizational structures and
funding and payment mechanisms. It may meet needs specifically associated with a
medical diagnosis (e.g., diabetes therapy) and/or may provide support for daily living
activities (e.g., bathing, cleaning, cooking). Home- care services serve a range of
people - from those with minor health problems and disabilities, to those who are
acutely ill and require intensive and sophisticated services and equipment. There are
no upper or lower limits to the age at which home care may be required. However, as is
true for other parts of the health system, use tends to increase with age.
Pharmacare / Pharmaceutical Issues
Pharmacare refers to a system of insurance coverage for prescription medicines. The
design of any particular system may vary in several respects. For example, a system
may be universal or offer coverage only to specific sectors of the population such as
seniors or social assistance recipients, etc. It may cover all drugs or particular
categories of drugs. A system could be financed publicly or privately, or both publicly
and privately and could include deductibles, co-payments, etc.
Relevant pharmaceutical issues include: accessibility, affordability, drug utilization and
compliance, prescribing practices, drug-distribution systems and information-system
infrastructure.
Primary Care / Primary Health Care
The HTF has adopted a broad definition of Primary Care/Primary Health Care. This
definition includes both a narrower primary-medical-service model, with a focus on
physician services, and a broader concept that encompasses a model in which a range
of providers of health and social services generally work in teams. First-level contact
with providers, co-ordination of services, health promotion/illness prevention, care for
common illness and managing ongoing health problems and services from a wide
range of providers are all part of this definition. We have opted to use the terms
"Primary Care" and "Primary Health Care" to reflect the different terminology used
across the country.
Specific examples of Primary Care/Primary Health Care services include (but are not
limited to): screening, health information, eye exams, treatment in the physician' s
office, vaccinations, hearing exams, prenatal care, home visits, nutritional counselling,
some mental-health services, drug-dispensing information, palliative care, etc. Primary
Care/Primary Health Care providers include family physicians, nurses in family
physicians' offices, public health nurses, nurse practitioners, pharmacists, nutritionists,
physiotherapists, midwives, chiropractors, long-term care providers, psychologists,
optometrists, social workers, etc.
Integrated Service Delivery
Integrated Service Delivery is the broadest of our four priority areas, and can include
the other priority areas. It refers to any effort or initiative that tries to better integrate or
co-ordinate a range of services which relate to health. The emphasis is on integrating
or co-ordinating services at the transition points in the health-care system - i.e., the
points at which one service (such as home care) takes over from another, e.g., the
hospital. Integration can occur on a system-wide basis, or focus on a specific link in a
particular community.
Integration usually involves a range of people and organizations involved in the
organization, funding and delivery of services. Co-ordination and integration could
occur along one or more of the following dimensions:
- across the continuum of physical and mental-health services - from prevention, to
primary care, acute care and continuing care - supporting health, well-being and
quality of life;
- across the range of delivery sites, including homes, ambulatory sites (such as
clinics and physicians' offices, diagnostic facilities, pharmacies), hospitals, and
long-term-care facilities;
- across service providers (for example, physicians, nurses, social workers,
physiotherapists); and
- across the range of planning and management systems or information systems.
How Projects Were Selected For Funding
Very early on, governments agreed to divide the $150 million into two parts: $120 million would go to
provincial/territorial projects (allocated to provinces and territories on a per capita basis) and $30 million
to national projects and other initiatives. These initiatives include the three national conferences
sponsored by the Fund in 1998 (on home care, pharmacare and the health infostructure), and the
development and implementation of a national strategy for synthesizing and disseminating information.
The operations of the HTF Secretariat were also covered by the $30 million for national use.
Decisions about provincial/territorial projects were made by the province or territory in question and the
Government of Canada. Provinces and territories had discretion in terms of how they would decide what
proposals to submit. However, all proposals had to meet the selection criteria agreed to nationally by the
FPT Working Group on the HTF(1). In general, provincial/territorial projects focus primarily on issues or
models that are of particular relevance to the health system of a province, territory or region, and they
generally take place exclusively within that jurisdiction.
In choosing which national projects to fund, the multi-lateral FPT Working Group reviewed more than 150 national proposals. In general, these projects address issues of interest to the health systems of several or all jurisdictions. Many, but not all, involve more than one jurisdiction.
The HTF received many more proposals for funding than could be accommodated, and funding decisions
were difficult. In some cases, very good projects were not funded - not because they had not been well
prepared and consistent with the Fund - but because other similar projects had already been funded or
because funding had been exhausted.
A General Profile Of Funded Projects
 
The amount of HTF funding for individual projects ranges from $6,000 to $18 million. These projects
relate to a variety of areas - from small, local issues to the system-wide reform of health care. In many
cases, the HTF is the sole source of funding; in others, it is one of several.
Of the 141 projects, 38 are national, and 103 are provincial/territorial. While projects have been
categorized for administrative purposes as relating to one priority area, in fact, many relate to two or
three. For example, the priority area of Integrated Service Delivery, by its very nature, often includes
elements of the other three priority areas: Home Care, Pharmacare and Primary Care/Primary Health
Care. Therefore, some projects categorized as Integrated Service Delivery have significant components
that relate in some way to the other priority areas.
In addition to the projects associated with each priority area, clusters of projects have emerged that relate to particular issues or populations. For example, a number of projects focus on populations such as
children, seniors, Aboriginal people, women and people with mental illnesses. Other projects deal with
specific issues around providing care in rural or remote geographic areas, or using telehealth and
telemedicine technology and information tools. Several others focus on issues relating to health
professionals (e.g., the use of nurse practitioners and collaborative teams involving different professions,
different payment mechanisms, etc.).
Types of Projects, by Priority Area
Home Care
To date, the HTF is supporting 30 projects that have been categorized as home care projects. Funding for
these 13 national and 17 provincial/territorial level projects totals almost $16 million. A number of other
HTF projects have a significant home-care component.
The home care projects address a number of issues and populations:
- the cost-effectiveness and appropriateness of substituting home care for long-term care in
facilities or care in acute-care settings;
- evaluations of models of home care to prevent further illness and avoid hospitalization or the
need for long-term care in a facility;
- testing ways to better integrate home care with the continuum of health services (across
particular geographic areas and populations), including integrated data tools and single-point-of-entry models;
- projects focussing on how to better meet the needs of seniors (e.g., for treatment of depression
and dementia, day-care programs, team approaches to providing care);
- home care for children;
- home-care models for Aboriginal populations, on- and off-reserve.
- evaluating and testing models of palliative home care;
- projects focussing on ways to assist informal caregivers (e.g., family members and friends of
people receiving home care) and to help assess their needs, improve their skills and explore ways
to prevent burn-out;
- providing integrated home-care and mental-health services.
Pharmacare
Most (13 of 18) pharmacare projects are national-level initiatives. Many involve information-sharing
between jurisdictions and explore issues such as access, appropriate utilization, and various approaches
to pharmaceutical program management (e.g., reference-based pricing and direct-to-consumer
advertising). Several patient-education initiatives are underway, particularly for chronic illnesses such as
asthma, and for conditions for which non-drug alternatives are under-utilized vis à vis drug therapy.
Several projects focus on ways of working with physicians to improve prescribing practices. Some
projects involve a stronger role for community pharmacists.
Primary Care / Primary Health Care
The HTF is supporting 38 primary-care projects. Most (32 of 38) are provincial/territorial level projects.
- A high proportion of the primary-care funds have been allocated to five system-wide provincial projects which pilot and evaluate different models of Primary Care/Primary Health Care delivery reforms. These large projects differ somewhat in their focus, but all look at ways to improve their respective Primary Care/Primary Health Care systems as a whole. These projects address some or most of the following issues:
- alternative arrangements for paying physicians;
- better integration of primary health-care services;
- better access to services either through extended hours and/or telephone health services;
- a stronger role for primary care/health care providers such as nurse practitioners; and
- integrated primary care/health care teams.
- Other issues and focuses associated with Primary Care/Primary Health Care projects include:
- different models for delivering primary care/health care services to particular target
populations (e.g., low-income people, First Nations, Francophone and Acadian communities
and people in remote areas);
- the use of health-care professionals (e.g., nurses, nurse practitioners, family physicians) to
provide "team" care in a collaborative setting;
- models for improving population health (for example, by increasing the opportunity for
children to live healthy and productive lives through preventing abuse, managing aggression
and early problem identification);
- improving pre- and post-natal care;
- approaches to both identifying and treating victims of violence more effectively, and
integrating offenders into the community more successfully;
- improving the management and co-ordination of various diseases, including asthma and heart
disease;
- assessing the use of health services by lower socio-economic populations;
- mental health;
- rural health; and
- telemedicine.
Integrated Service Delivery:
Projects dealing with the integration of health-care delivery have received significant support from the
HTF. In total, roughly $60 million has been allocated to 6 national and 49 provincial/territorial projects
that focus primarily on Integrated Service Delivery. A number of projects categorized as Primary Care
and Home Care projects also deal with the integration of the health-care system.
Specifically, Integrated Service Delivery projects test and evaluate a broad range of approaches to
improving integration. The breadth of these projects clearly indicates that a range of approaches to
improving the integration of the health-care system are possible. These projects also show that efforts to
better integrate the system can be carried out at different levels. For example, integration can involve:
- better on-site access to specialized expertise and care for rural, remote and Aboriginal
communities (including through telehealth/telemedicine);
- better management of waiting lists for health procedures;
- better co-ordination of health and social service delivery for the population in general and, in particular, seniors, youth, Aboriginal peoples, and the terminally ill.
- developing mechanisms and tools to improve the way in which services are planned and delivered;
- better integration and co-ordination among professionals in health and other sectors (e.g.,
researchers, social workers, hospitals and community organizations);
- integrating community- and home-based care more closely with the health system;
- "single-window" access to a wide range of health-care services; and
- strategies for promoting health and preventing illness in addition to merely delivering care.
A Word On Project Monitoring
The Health Transition Fund Secretariat is publicly accountable for the funds being spent through its
funding program. Therefore, it is necessary to monitor the financial and administrative activities of
projects and their actual progress. Accordingly, the HTF has (and is) carrying out a number of specific
monitoring activities:
- evaluating proposals, to ensure that they meet the HTF criteria;
- before authorizing payments, reviewing the financial claims from projects and checking for
consistency with the projects' approved budget and workplan;
- reviewing interim reports from projects against their approved workplans and budgets;
- reviewing and assessing specific requests from projects to approve changes to their workplans and
budgets;
- visiting sites or meeting with staff from certain projects to improve the Secretariat's familiarity with,
and understanding of, the nature and progress of these projects; and
- carrying out a limited number of audits to ensure that projects are using funds in an approved
manner.
Synthesis and Dissemination
The HTF's mandate is to support projects that contribute to "evidence-based" decision making. Such
projects will provide evidence which governments and others can use in making health-related decisions.
Clearly, therefore, the project results - i.e., the evidence - has to reach decision makers in a way that will
permit them to either use it immediately, or remember that it exists and retrieve it when they need it.
Accordingly, the HTF will continue its ongoing efforts to ensure that a system or protocol is in place for
getting all information flowing from projects to those who can use it.
The Fund requires that individual projects take the lead in disseminating their results. The dissemination
activities for projects vary with their size and scope, but they generally include distributing final reports
to targeted audiences, submitting articles to professional newsletters and academic journals, distributing
information electronically and giving presentations at conferences. Some projects also have web sites
that describe the project, indicate its activities to date, etc.
The HTF may assist with disseminating the results of certain individual projects. However, generally we
will concentrate our dissemination efforts on broader-based, more analytical work. Specifically, we will
consolidate or "roll-up" the results from the many reports we receive and highlight and share any
particularly interesting information and general trends that emerge across projects. When consolidated
and analysed, the entire pool of project results will offer much potential for generating useful evidence
and policy-relevant lessons that should be applicable in a number of provinces and territories.
In addition to having access to the findings of individual projects, the Fund wants to know what the projects say, collectively, about broad reform direction or models for delivering services, in terms of
what works generally, not just what works in a particular city, with a specific population. Therefore, the
HTF has developed a national strategy for consolidating, analysing and disseminating project results. In
developing this strategy, we consulted various decision makers in the areas of health policy and programs
- e.g., federal, provincial and territorial government officials and representatives of regional health
authorities. We also consulted with project investigators, representatives of research bodies and national
health organizations and people experienced in disseminating information.
Here are the elements of the strategy, which are based on these consultations and on discussions of the
FPT Working Group:
- Consistently formatted, bilingual fact sheets that describe each project and present its results. These
sheets will be produced in collaboration with individual projects and made available in hard copy and
electronically.
- Five analytical syntheses - one for each priority area and one "umbrella" synthesis - to consolidate
findings from individual projects. They will emphasize the practical lessons learned through the
HTF: what worked and what didn't and the conditions for (and barriers to) success. Syntheses will
also emphasize transferability issues - what is relevant for other sites, regions, services and
jurisdictions.
The syntheses will use the four questions (see p. 4) in the HTF Evaluation Framework as a basis for
consolidating findings. The four questions deal with issues relating to quality, access, integration,
health impacts, cost-effectiveness, and transferability. Not all projects are expected to answer all four
questions in the same detail. However, these questions do provide a foundation for analysing and
organizing the results of individual projects. In turn, these results will provide the raw material for
the national consolidation. The HTF will therefore rely on the evaluation work done by each project
to provide results that relate to as many of the four questions as are relevant to that project.
We may produce other synthesis material - for example, for projects relating to Aboriginal health,
rural/remote health and telehealth.
- The HTF will make or arrange for presentations on projects and results to various events such as
decision-maker meetings, conferences, workshops, consultation events, etc. In-person briefings have
been shown to be an effective way to communicate information, and we intend to use them as much
as possible in disseminating project results.
- In collaboration with partners, the HTF will develop special events or publications to share project
results in appropriate venues and with appropriate audiences. These will be identified as
opportunities or needs emerge, and will be a responsive, dynamic element of the strategy.
- We will make maximum use of information technology, such as the Internet. For example, the Fund
is exploring how to make our web site more user-friendly and provide access to projects addressing
various topics. In addition, the HTF plans to develop an email to notify users when new documents
become available. Of course, hard-copy versions of all publications will still be available, and a
mailing list will be maintained for those who may not have ready access to the Internet.
- The HTF is also considering how to layer information, so that readers can start with summary
information and delve deeper if they so choose. For example, a list of projects (layer one) could refer
to fact sheets. In turn, these sheets could point to web sites that contain more detail and indicate how
to obtain copies of project reports or other information products.
The HTF is only one source of health-related information and evidence. Accordingly, we would hope that the results of HTF-funded projects can be structured and disseminated in such a way that they add to the stock of available evidence and remain accessible to decision makers over time. To some extent, our success in doing so will depend on our ability to link or add information flowing from HTF projects to other programs and sources of information.
Some Lessons Learned
This section offers some general observations and comments on the program and our experience with it
to date. We also indicate some of the things which those who have been directly involved in managing
HTF projects have learned about the process.
Observations on the Program
The HTF is a national program of applied research, providing the opportunity to test new approaches to health service delivery in real-life health-care settings. Early on, it became apparent that there were more good ideas about how to improve service delivery than we would be able to fund - there are literally hundreds of committed people and organizations that want to make improvements to the health system in their sphere of influence, and are thinking creatively about how they could make a difference. At the same time, with the focus on applied research, there was some initial skepticism about whether the projects supported by the HTF would embody the research methodologies needed to generate useful information. Given the HTF's mandate, it is important that projects use methodologies that both work in the field and will provide useful and relevant information to policy makers. Project investigators and other members of the research community have repeatedly expressed their enthusiasm for the unique opportunity provided by the HTF to test new approaches in the field.
Our experience in developing and managing the funding program and jointly planning and hosting the national conferences has underscored both the need for an open and collaborative approach, and the benefits of such an approach. Partnerships were sometimes logistically complex - particularly given the 14 jurisdictions, two languages, five time zones and variations in terminology and differing policy and research environments. Undoubtedly, the differences have enriched the program, and working together has strengthened its quality and relevance.
In addition to working closely with other governments, the HTF also sought advice from experts in
several areas - notably program design, the national evaluation framework and future synthesis and
dissemination activities. Working with these people has proven very worthwhile and has enriched the
value and potential contribution of the HTF.
From the outset, the program has been interested in evaluation at several levels and has tried to place
evaluation "front and centre" as the basis for evidence-based decision making. The development of the
national evaluation framework as a guide for investigators was an important step in this regard. The HTF
Secretariat has worked with project proponents to ensure that they address the evaluation framework - in
some cases, this has turned into an ongoing process, as evaluation plans, and expertise, evolve over the
life of the project. Not surprisingly, given the range of projects being funded, different projects were
better able to focus on different elements of the framework. In particular, it has been necessary to devote
a considerable amount of effort to clarifying the ideas of "transferability" and "generalizability". This is a
key element of the HTF - how lessons learned in one place can help others in another. Therefore,
continuous education and explanation will become even more important as we near the end of the HTF
program, as efforts increase to consolidate, analyze and share results and lessons across Canada (see also
Synthesis and Dissemination section).
Related to "transferability", given the complexity of many of the projects, and also their innovative
nature, it is becoming ever more apparent to us that the evaluation of the processes undertaken in projects
is key, both for moving a project beyond a pilot stage, and for transferring the knowledge to others.
One more point on evaluation: Ironically, because of the HTF's focus on evaluation and the need for
evaluation expertise, many of Canada's experts in this discipline had already been engaged in various
ways to work on HTF projects. Accordingly, some projects were faced with a shortage of evaluation
expertise.
Time has proven to be a highly valuable resource. Given that the HTF is a new program, there was some guesswork and uncertainty about overall, projected time lines. In reality, we have found that almost everything, including project selection, took longer than anticipated. More time was required than originally planned to operate the program, so that the research could take place properly. Minister Rock recognized the importance of time and allowed an extension of the HTF mandate to better ensure the quality of results and dissemination. Even with more time, there are still some challenges. Evaluating outcomes takes time, and few programs can offer the longer-term funding needed to carry out the longitudinal evaluation studies that would be desirable.
Finally, even with funding available, we have learned that some good ideas are difficult to get off the
ground. There were three projects that were approved for funding under the HTF which did not
ultimately proceed, as they were unable to liberate, mobilize or recruit the health professionals required.
Observations on the Projects
The HTF has ongoing contact with investigators. Over time, they have shared with us their experiences and what they have learned about developing and implementing their projects. Some observations noted below apply to almost all projects, and others may relate more to certain types of projects. However, collectively, these formal and informal observations constitute a record of experience and what has been learned in designing and implementing projects.
The level of commitment of the project proponents or investigators in every project is unvaryingly high.
While the projects vary in terms of size, scope and subject, each involve people and organizations
determined to make improvements. Having said that, trying something new and conducting research in
"real-life" settings is complicated and difficult to predict. The focus on "challenges" here reflects this
reality as projects work through their start-up phases. Learning which models work, and which ones do
not, will be more apparent towards the end of the projects and the program. It is also interesting to note
that a number of project proponents have suggested that with the HTF, their project would not have been
undertaken.
Administration and logistics were time-consuming
Almost everyone who submitted a project proposal indicated that everything took longer than expected.
This was especially true for start-up activities - the mechanics of getting everything and everyone on
board.
- The final identification of sites and the establishment of partnership agreements were more complex
and time-consuming than expected. Contacting the right person in an organization, sorting out roles
and responsibilities and internal funding and communication issues, along with finalizing
partnership agreements, all took time.
- Recruiting qualified staff was a problem for many projects - particularly in rural and remote regions.
However the recruiting problem was also due in part to more systemic or province-wide human
resource issues that delayed staffing. For many projects, staff had to be trained to carry out one or
more activities. For example, they may have had to either learn to use new software, or receive
training on the particular cultural requirements of a given group of clients. Others may have had to
become familiar with research protocols generally. Again, those in charge of projects often found
that the development and implementation of training took longer than anticipated.
- Recruiting patients to participate in projects was also more difficult and time- consuming than
anticipated, given that patients with very specific characteristics were often needed. Even with high
enthusiasm among potential patients, some projects were faced with either recruiting fewer than the
ideal number of patients, or taking more time to find them - which could reduce the duration of the
project and the validity of the findings. Of course, a number of projects were well subscribed with
patients and were able to increase the size of study groups or offer services outside the scope of the
projects themselves. However, generally speaking, projects reported that recruiting enough patients
(and recruiting them quickly enough) was a challenge.
- Investigators found that information and information technology present many challenges. For
example, key technical activities such as tailoring information systems, making new information
systems compatible with old ones, ensuring compatibility among partners' systems and reaching
consensus on definitions took a great deal of time. Similarly, for projects that relied on existing
administrative data bases, accessing data was often considerably more complicated than expected.
Finally, many projects, and particularly those involved with electronic data collection, faced
problems relating to privacy issues. In general, these problems were eventually surmounted, but they
often caused delays.
- Projects often reported that obtaining ethics approval took more time than was initially expected.
Projects (especially national projects) that were being carried out at more than one site faced these
challenges to a greater extent than did single-site projects. For example, they needed to obtain ethical
approvals not just from several institutions, but in several jurisdictions. They also had to cope with a
range of legislation, health-services programming and insurance plans. Using data from several
jurisdictions - each with different content, structure, compatibility and comparability - posed particular
challenges for multi-site projects.
Consultation is critical
Experience has underscored the need for broad collaboration, consensus building and consultation among
all parties from the beginning and throughout all stages of projects. Partnerships were a specific form of
collaboration that always needed special and prolonged attention.
In general, consultation is both a condition for success and a challenge because of the time and effort
required. However project staff have indicated that time invested in consultation activities has paid off.
Indeed, adequate consultation and communication are viewed as important not only in carrying out
projects, but in increasing awareness generally about the potential benefits of future reform. A study
which evaluated the effect of closing rural hospitals in Saskatchewan underlined this fact. The study
found that residents of communities in which hospitals had been closed regarded early and meaningful
consultation as critical to implementing change.
Evaluation and dissemination needed careful planning
These elements, in many respects the raison d'être of the HTF, prompted many comments and observations from proponents of projects and project investigators. Comments ranged from questions about the need to evaluate at all, to how to obtain expert support to satisfy the requirements of the HTF's evaluation framework. The Fund intended, from the beginning, to foster a culture in which investigators would routinely think about evaluation and dissemination as they planned research. However, investigators did not all do so to the same extent.
As noted earlier, we required all project proposals to include an evaluation plan (although some projects
were evaluations in themselves) and a dissemination plan. The costs of these activities were to be
included in project budgets. More than a few proponents were surprised to be asked up front for these
plans - particularly proponents from the health-services field as opposed to academia. This requirement
created a demand for evaluators, and it pointed to the need for more people with evaluation expertise.
At this stage, most proponents seem confident that they will be able to satisfy the elements of the national
evaluation framework that apply to their projects. Most investigators, however, have noted that it will be
difficult for them to evaluate the impact of their projects on health outcomes, given the longer time lines
needed for such evaluation.
Staff shortages have affected some projects
Projects are closely connected to the real-life, day-to-day operations of health systems, which are always
are under pressure for time and money. Some proponents noted that hospital staff already have very
heavy workloads. Therefore, they are not always available for the additional work associated with the
projects. The shortage of nurses has affected many projects significantly. Staff shortages have led to
changes in the design of certain projects. In some cases, it has meant choosing one site over another. Not
surprisingly, proponents' experiences with HTF-funded projects underscore the applied nature of their
research; many have had to face the same "real-world" challenges confronting people who are delivering
services and developing programs on a day-to-day basis.
What's Next?
Only a few projects have submitted their final reports to date. About half the projects will submit final
reports by the fall of 2000 and the rest by spring 2001. As they report, projects will disseminate their own
results. In the meantime, we will continue working on developing our synthesis and dissemination
processes, including making our web site more user-friendly and adding fact sheets on project results as
they become available. Once most projects have submitted their final results, our synthesis and
distribution efforts will accelerate, and the results will be visible in early 2001.
For More Information...
For more information on the HTF, or to get the name of your provincial or territorial representative on
the Federal/Provincial/Territorial Working Group on the Health Transition Fund, you can reach us:
At our web site: www.hc-sc.gc.ca/hcs-sss/finance/htf-fass/index_e.html
By phone: (613) 954-6777
By mail: Health Transition Fund Secretariat
Health Canada
11 Holland Avenue, Suite 709
Postal Locator 3007A
Ottawa, Ontario
K1A 0K9
By fax: (613) 954-1447
By email: htf-fass@hc-sc.gc.ca
Commonly Asked Questions About The HTF...
Why did the Government of Canada establish the HTF? What is its purpose?
The HTF was established by the Government of Canada in response to a recommendation from the National Forum on Health. The Forum recommended the creation a multi-year fund to support evidence-based innovation related to home care, pharmacare and primary care, to help move toward a more integrated health system.
The purpose of the HTF is to fund to projects that test practical approaches to health-care delivery to
see if they work, and why they do or don't. This will generate evidence that decision makers across
Canada will benefit from as they work to reform the health system nationally or at the provincial,
territorial and local levels.
Why are governments investing such time and resources into pilot studies, rather than simply making broad systemic changes?
The health-care reform literature strongly concludes that evidence-based decision making greatly
improves the potential for introducing change successfully. Pilot studies can provide this
evidence by examining proposed changes to assess the extent to which they produce (or do not
produce) positive outcomes. In effect, pilot studies reduce the risk that problems and failures will
occur by testing new approaches in a limited way before implementing them on a broad scale.
Are funds still available for new projects?
No. At this stage, we have allocated all of our funds, and no further rounds of funding are planned.
Will there be a follow-up to the HTF?
Currently there are no plans for a follow-up to the HTF. The HTF was meant to be a one-time, time-limited effort. The HTF is unique in Canada. At the end of its mandate, it will be evaluated to
determine how effective it has been in generating useful information to improve the health system.
Is this a collaborative initiative among federal/provincial/territorial governments? How does this work?
While the money is provided by Government of Canada the effort is a collaborative one, involving
the Government of Canada and all provincial and territorial governments.
A working group with one representative from the Government of Canada and each provincial and
territorial government was formed to guide the Health Transition Fund. For provincial or territorial
projects, each jurisdiction worked with the Government of Canada to select projects to recommend
for funding. For national projects, the working group as a whole made recommendations about which
projects should be funded. The federal Minister of Health made final decisions based on the
recommendations.
How was the money for provincial and territorial projects allocated?
Of the $150 million, $120 million is supporting provincial and territorial projects. This $120 million
is divided amongst the provinces and territories on an equal, per capita basis. Each province and
territory had its own way of identifying projects, which it submitted to the Government of Canada for
approval.
When will the results from HTF projects be made available, and how can I access them?
Most results will be available in the latter part of 2000. Some projects, particularly smaller ones and ones with shorter timelines, have already presented their results, and some others will be available in early 2000.
Each project will be making its results available to target audiences. Summary information on each
project and its results will be available in hard copy and on the HTF website shortly after we receive
them. This summary will provide contact information on the project for those who want more
detailed information.
To complement the communication efforts of the individual projects, we will do an "umbrella"
analysis of lessons learned, and an analysis for each of the four priority areas. Efforts are underway
to determine how this information should be presented and to whom. While information will always
be available in paper form, we are looking to exploit web technology as much as possible to help
people find the particular information they are looking for.
How will projects be able to measure their effect on the health of the population they are serving, given that it takes time for health benefits to become apparent, and that projects are being funded for only a relatively short period?
The time-limited nature of the HTF does make it difficult to assess how some initiatives have
affected health. It is true that, depending on the type of projects, health benefits or negative effects
cannot be measured until 5, 10 or even 20 years later.
We are asking projects to identify the impact on health that their particular project has had, where
possible. In some cases, this will be through proxies (for example, if a project has demonstrated
success in getting people to change their behaviour, and research has demonstrated that such a
behavioural change is beneficial to one's health). Some projects will have more immediate effects,
which they will be able to measure.
1. To be considered for funding, proposals had to meet the following criteria: pertain to one of the four priority areas;
have national relevance; explore a model likely to offer pragmatic, effective and efficient reform options; not duplicate projects or
efforts already funded by the federal government; be consistent with the principles of the Canada Health Act with respect to
insured services; demonstrate capacity to complete the project; include a plan to evaluate the project; and include a plan to
disseminate results. Proposals were also assessed in terms of their national significance, importance to provincial/territorial health
systems, attention to health inequities, and the extent to which they supported improvements to the health and well-being of the
population.
|
